The novel; Erewhon, an anagram of nowhere, is the name of a utopian place imagined by the English writer Samuel Butler and described in his satirical 1872 novel.

To access that country, you must cross an intermountain pass, flanked by giant statues that warn of the risk of doing so, according to the author. Entering this area is so dangerous that the narrator illustrated the fact with a specific musical recommendation; listen to compositions by Georg Friedrich Händel for harpsichord, published by Henry Litolff. Sarabande, perhaps? In short, music with image.

Erewhon, or on the range, is a paradoxical place where the economic-financial system is religion, the educational system is a way of repressing originality, technological mechanisms or innovations are prohibited, time is an imposition of clocks, conformism the ideal attitude, the individual's health an obligation for each one, diseases are crimes and illness, the worst of faults. Avoiding improvement or even change is a pathetic norm in that world. To promote healthy lifestyles in that society.

If someone falls ill, they fall from grace. Not only because his biological or mental condition is a reality, but procedurally, that person is subjected to a social trial and condemned as a criminal. The sentence, pay large sums of money to an authority without representation and remain bankrupt economically (far from his faith) and morally (far from others). Erewhon, paradise of inequalities in access to disease treatment.

Consequently, prevention is prevented there. People avoid going to the doctor, even though numerous signs and symptoms appear and if they are discovered by the police or health guards, they are quickly reminded that life after death does not exist, only before birth and therefore, the rebirth, is the only path to redemption. Erewhonians do not avoid death.

Here and now

Although the author attempted to criticize the Victorian society of his time, many places like this in different ways, still exist today. In some modern societies, one of the main causes of family bankruptcy is if one of its members suffers from a rare or economically catastrophic disease, as we usually call it.

In others, for a large part of the population, educating themselves to distinguish and practice healthy lifestyles, reaching timely health services in time, space, and circumstance, without desperate waiting lists, or being able to face disability or the elderly with dignity and enough community support, it is a pending challenge.

A professor at the Universidad Complutense de Madrid, Dr. Francisco Villota, had already suggested it; Erewhon, it is a great argument to justify good health services from public spending or mixed public-private financing.

Health, a national state policy

With the intention of keeping Costa Rica away from Erewhon, as it has been doing for more than 8 decades now, the National Health Policy “Dr. Juan Guillermo Ortiz Güier” is here. There are 10 years of continuing to strengthen the primary care level, inspired by the Hospital Without Walls (“Hospital Sin Paredes” in Spanish). The care model, which was developed in 1955 by Dr. Ortiz Güier, was consolidated in the 1970s in the Western Region of Costa Rica, and the World Health Organization (WHO) in its Alma-Ata Declaration of 1978, called it primary health care.

Costa Rica changed the Hospital Without Walls program to the primary health care model recommended by the WHO in 1985. With the Costa Rican Health Sector Reform, the Basic Health Care Team (EBAIS in Spanish) and the Stewardship of the Ministry of Health were promoted.

The Primary Health Care Technical Assistants, or ATAPS in Spanish, have been a fundamental part of the EBAIS, inspired by the former Rural Health Assistants, or Malaria Technicians, from the Ministry of Health. Officials, who had been a fundamental piece in keeping the Family File and the Analysis of the Integrated Health System (ASIS in Spanish) updated at the local level, during the last decades of the 20th century and who were lost at the turn of the century, in many regions of the CCSS, when the powers of comprehensive care were transferred to it.

With the launch in July 2015 of the National Health Policy “Dr. Juan Guillermo Ortiz Güier," the main strategies of primary health care, community medicine, and health education were resumed, which made the Hospital Without Walls model and program successful during the period 1955-1985.

The National Health Policy “Dr. Juan Guillermo Ortiz Güier” was founded on a set of principles and transversal axes, aimed at equity, opportunity, and quality in health, as well as the reduction of social gaps and the sustainability of the Costa Rican health system.

Thanks to this, the need to keep the ASIS and the family file updated was resumed, and to this end, in 2017, 100% of the latter was digitized by giving each of the ATAPS portable tablets with an internet connection, to complete during their stay. at home visits throughout the national territory. This, added to the Single Digital Health Record (EDUS in Spanish), was awarded and internationally recognized and was 100% fulfilled at the three levels of care and with Universal Coverage, in 2018. Both are very powerful tools for data collection and processing. Big Data can be used to improve decision-making in CCSS senior management.

The health policy proposed the way forward, and the CCSS provided the budgetary means of financing. According to the two Costa Rican Health Account System Reports, the average/year distribution of CCSS expenditure for the Health Care Areas or Primary Care Level increased by 14%, from 25.08% for the year group 2011 to 2016, to 39% for the period 2017 to 2019, compared to the percentage assigned to Hospitals and Specialized Services (Second and Third Care Levels together), which in the same period fell from 64.08% to 49.75%, respectively.

This health policy promoted epidemiological surveillance as a matter of national security, resuming the vector control program at the national level in 2015 to fight against the mosquitoes that transmit the ZIKA, dengue, and Chikungunya viruses. Likewise, for the training of specialists in epidemiology at the master’s level in 2014 and technicians in medical entomology in 2016, both contracts were signed with the Universidad Nacional de Costa Rica. In 2018, the specialty in preventive medicine and public health for medical practitioners was registered with the College of Medical Practitioners and Surgeons of Costa Rica and the incorporation of health promotion professionals from the Universidad de Costa Rica* to that same college was by direct request from the Minister of Health in 2016 and began to be hired at the CCSS.

The Health Economics specialty for economists and the Health Promoter profession were also registered with the General Directorate of the Public Service of Costa Rica in 2016, which allowed the Costa Rican Ministry of Health to recruit human talent in those areas. For the first time in the history of Costa Rica there was appointed a Vice Minister of Health Promotion in 2015.

Regarding infrastructure at the first level of care, this health policy developed a portfolio of investment projects in infrastructure and technologies approved by the Board of Directors of the CCSS in 2017, which would reduce the gap in the number of primary care centers, with the construction and equipment of 33 new EBAIS and 21 health area headquarters that are currently under construction, expansion, or remodeling.

The Board of Directors of the CCSS, in its ordinary session on February 15, 2018, allowed, for the first time in the history of Costa Rica, the creation of 10 new EBAIS with exclusively evening hours, which allowed the benefited localities to attend to the population. being able to make consultations in the afternoon, without losing hours of work or study in the process, optimizing the use of installed infrastructure.

For having devised the Hospital Without Walls care model, the WHO awarded Dr. Juan Guillermo Ortiz Güier with the 1999 Sasakawa Prize, and the Costa Rican Congress declared him Benemérito de la Patria, on April 13th, 2015.

As Minister of Health of Costa Rica, on January 25th, 2016, with the Congressman and Chair of the Costa Rican Congress, Lic. Rafael Ortiz Fábrega, and the Chair of the Costa Rican Social Security Fund (CCSS), Dr. María del Rocío Sáenz Madrigal, all authorities by the time; together we reveal the official photograph of Dr. Ortiz Güier in the Western Regional Directorate of the Ministry of Health.

We also discovered a bust, a tombstone with a heart, and an original poem written by the same honorable doctor. All this, thanks to thousands of volunteers, the Sociologist Don Miguel Ángel Sobrado Cháves, and especially a group of former collaborators of the program and care model Hospital Without Walls: Mrs. María Elena Montalvo, Mrs. Jeannette Quirós, and Mrs. Rita Méndez Villalobos, all of them faithful witnesses of the work of the Benemérito Doctor, who contributed significantly to Costa Rica, avoiding Erewhon.